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Orthopaedic EOPW (2nd attempt) 20/03/2018

1. Cartwheel lesion
- Pleomorphic sarcoma
From orthobullet
- Pleomorphic sarcoma is a malignant fibrogenic tumor that occurs in patients from 30-80
yo - similar to fibrosarcoma of soft tissue in presentation and treatment - Classic histology
characteristics are :-
a) spindle and histiocytic cells arranged in stroiform (cartwheel) pattern
b) chronic inflammatory cells may be present

5. What is the radiological features of osteoid osteoma?

a. Cortical destruction and central
b. calcification in cartilage cap
c. Onion-peeling appearance at diaphysis of femur
d. Sunburst appearance with periosteal reaction
e. Cortical thickening with central lytic lesion (nidus)b6

6. What is the radiographic features of Giant Cell Tumor ? C. Soap bubble appearance at epiphysis
Osteolytic lesion at metaphysis

12. 60 years old lady presented with swelling over left thigh for past 3 months. The swelling increased in
size rapidly. Loss of weight for 7kg. The swelling was located at medial aspect of thigh measuring
10x15cm. What is the most specific bioimaging for diagnostic purpose?
A. CT scan of left thigh
B. CT scan of lung
C. MRI scan of left thigh
D. Ultrasound of left thigh
E. Plain radiography of left thigh

14. Old man presented with multiple site bone pain. Pale and thin. DRE showed diffuse enlarged and
firm prostate. Left LL shortened and external rotated.
Investigation: Pancytopenia
X-ray : diffuse osteolytic lesion on pelvis and proximal femur

What is the diagnosis

A. Multiple myeloma*
B. Chronic myeloid leukaemia
C. Prostatic carcinoma
D. Primary bone lymphoma
E. Osteosarcoma

15. 20 year old man in MVA. presented with left lower limb shortening. X ray showed posterior hip
dislocation. You were asked to do a neurological examination. Which will you do? A. Check anal
tone B. Check ankle reflex C. Check power of vastus medialis D. Check power of extensor hallucis
longus
E. Check sensation of inguinal region
21. 43 year old woman complains of pain after injured her 2nd right toes after accidentally kick the table.
On examination the toe is swollen and not malaligned. X-ray shows a non-displaced fracture of proximal
phalanx. What is your next treatment? (I’m confused about the option, better find out the answer for
fracture toes yourself)
a. Below knee cast and non-weight bearing.. (for displaced metatarsal bone fracture from Apley 9th
edition (black) : pg 931)
b. Give analgesia and non-weight bear for 6 weeks
c. Reassure the patient that weight bearing is allowed and TCA in clinic?
d. Buddy splint and allow weight-bearing
e. Apply boot cast
Ans: Apley 10th edition page 963, patient encouraged to walk in a supportive boot or shoe. If pain is
marked, the toe may be splinted by strapping to its neighbour for 2-3 weeks (buddy splint)

22. 50 years old man with short limping gait

- Right leg appeared to be shorter than left
- What is the physical examination to confirm the diagnosis
A.
B. Flex the hip and knee in supine position
C. measure from ASIS to medial malleolus for length discrepancy in supine position
D. Measure from xiphisternum to medial malleolus for length discrepancy
E.

27. Pt with urinary bowel incontinence how to assess level of lesion

A. Check dermatome from neck to knee
B. Check dermatome from umbilicus to toe
C. Check anal tone
D. compare the reflex between knee and ankle

28. 38 years old male presented with pain and numbness over right foot. The pain travels to big toe.
Motor power of dorsiflexion was 3/6 with reduced sensation over medial aspect of right foot.
A. Foraminal herniated disc L3/L4
B. Foraminal herniated disc L4/L5
C. Central herniated disc L2/L3
D. Posterolateral herniated disc L4/L5
E. Posterolateral herniated disc L5/S1

30. Presented with low back pain for 3 months. The pain woke him up in the night associated with cold
sweat. Multiple injection scar seen on the upper limb. What will you seen in the x-ray?
A.Scoty dog appearance
B.End plate erosion
C.Collapse of posterior column
D.Pedicle fracture
E.Corduroy vertebral body ( vertically-oriented, thickened trabeculae seen in intraosseous haemangiomas of the
spine. It is the sagittal/coronal equivalent of the polka-dot sign seen on axial imaging. Signifying vertebral
haemangioma)
The Scottie dog sign refers to the normal appearance of the lumbar spine when seen on oblique radiographic
projection. On oblique views, the posterior elements of the vertebra form the figure of a Scottie dog with:
● the transverse process being the nose

● the pedicle forming the eye

● the inferior articular facet being the front leg

● the superior articular facet representing the ear

 ● the pars interarticularis (the portion of the lamina that lies between the facets) equivalent to the neck of the
dog. If spondylolysis is present, the pars interarticularis, or the neck of the dog, will have a defect or break. It
often looks as if the dog has a collar around the neck (or decapitation for those with a bloodier imagination).

31. Pre-op fasting, give maintenance fluid. Patient is 70kg. Calculated to give 2.1L fluid. What fluid
should be given?
a. 500ml NS & 1.6L
b. IV 1050ml NS & enteral 1050ml D5
c. 1100 ml Hartmann solution & 1100ml D5
d. 1000ml IV dextrose 5 and IV 1100ml NS
e. 1100 ml NS & 5 % dextrose water

37. A 60 year old presented with 1 day history of low back pain. He walked his dog and tripped and felt.
His X-ray showed a left subtrochanteric fracture of femur and multiple diffuse lytic lesion at proximal
femur. Urine electrophoresis showed presence of immunoglobulin light chain. What is your diagnosis?
a. Multiple myeloma
b. Paget dz of the bone
c. Metastasis from prostate ca
 d. ..
e. ..

38. A 21 years old girl came in to your clinic and diagnosed with ingrowth nail. How would you manage
her? A.Ask her to cut her nail short and follow the shape of the nail B. C.Ask her to cut the nail
straight with the edge of the nail long
D.Avulsion
E.

43. 7 months of bone pain. Calcium high. ALP very high. GGT 46 (normal)
a. Paget disease (normal calcium level, raised ALP)
b. Hyperparathyroidism
c. Osteoporosis
d. Osteomalacia
e. Osteosarcoma

44. A man presented with left wrist pain after fall on outstretched hand. X-ray showed left distal radial
fracture with dorsal displacement and intra-articular involvement.
Extraarticular fracture : Colles and Smith’s fracture
Intraarticular fracture : Barton’s & Chauffeur’s
fracture

A. Closed reduction and percutaneous k-wire

B. Closed reduction and external fixation
C. Open reduction and internal fixation with plate
D. Closed reduction and cast
E.

46.DM, HbA1c 11%. Presented with fever, swollen and painful LL. Ulcer at 4th digital space and purulent
discharge. What you want to do?
A.Give IV abx and IV fluid
B.Give oral Abx and discharge for outpatient daily wound dressing
C.Give IV analgesic and LA for wound debridement
D. give oral abx and oral hypoglycemic agent

51. A 1 year old child was brought by parents for bilateral bowed knees. They first noticed the deformity
one months ago after he started walking. On examination, you could not elicit any abnormalities apart
from the genu varum (angulation 10 degree). How are you going to advice the patient?
a. Reassure that this condition is self-limiting and normal variant up to 2 years of age
b. Advice the parents that the child need skeletal surveillance each month until 4 years of age
c. Tell the patient that the child need screening for osteogenesis imperfecta
d. Tell the patient that the condition will worsen without surgical intervention
e. Advice the patient for a custom made brace for the child’s condition.

54. 50 years old woman presented with low back pain for 3 months, initially treated with traditional
healer, worsening for the past 2 weeks. There was no history of trauma prior to pain. The mammogram
done 6 months ago was normal. What is the important history?
A. Recent travel to jungle
B. Pain while walking to toilet at night
C. Pain that wakes him up at night and relieved by movements
D. Numbness of the limb
E. Pain radiate down to foot
EMQ 59-60
Hypertrophic non-union
Non-union
Malunion
Acute osteomyelitis
Chronic osteomyelitis
Septic arthritis

59. Old man come in with right knee pain for 6 months. History of femur fracture not treated with surgery.
On examination shows a valgus deformity at right knee. Malunion

60. A child presented with acute onset of limping and pain of left lower limb. On examination, the child is
fever, toxic looking. He refuses any movement over left hip. Left knee and ankle examination are normal.
Septic arthritis
(not acute OM?) ( clues bcoz he is unwilling to move his hip joint and OM will have tender swollen,
erythematous limb)

Unsure of numbers

1.A 13 year old boy was told by the surgeon to do below knee amputation for osteosarcoma with neural
invasion. THe boy refused. WHat you want to do?
a) Get 2 consultant decision to proceed with surgery
b) Counsel the parents and children the benefit of doing the BKA
c) Counsel the parent about limb salvage surgery
d) Proceed with surgery and the child is too small too give consent

2) Patient with symmetrical finger tender and stiffness, worse on morning. Now she come in presented
with right knee swelling and pain. On examination, the right knee is tender. The other joints are normal.
What X ray feature will be seen?
a) Juxtaarticular osteopenia
b) Narrowing of Joint space
c) Subchondral cyst
d) Subchondral sclerosis
e) Osteophyte

3) A patient had motor vehicle accident. His hip is adducted, internally rotated and flex. What injury he
had?
a) Posterior hip dislocation
b) Anterior hip dislocation

5) An elderly lady had fracture of the neck of femur. The consultant decided to manage her
conservatively on skin traction. In the ward, she suddenly developed shortness of breath. She was
confused, tachycardia and tachypnoea. An ABG was done and showed a picture with T2RF. What is her
most probable diagnosis?
a) Pulmonary embolism
b) Fat embolism

6) Patient currently had knee pain, worsening in nature. She also had stiffness and tender over her
fingers. ESR and CRP are high. Other physical findings are normal. What is her most probable
diagnosis?
 a) Osteoarthritis
b) Rheumatoid arthritis
c) Gouty arthritis
d) Septic arthritis

7. A man sustained a laceration wound over 2nd, 3rd and 4th digit after a fight. Examination showed a
injured FDS tendon but spared FDP. he underwent primary repair of tendon. Which splint should be
used to immobilised the hand?
a. Dorsal splint of finger and wrist only
b. Dorsal splint of finger, but not wrist or elbow
c. Volar splint of finger and wrist
d. Dorsal splint of finger, wrist and elbow
Ans from Dr Sachin; Dorsal extension block splint with wrist neural, MCP in 75 deg flexion, ICP straight
(Position of safe immobilization) and elbow in 90 deg flexion as FDS originates proximal to elbow
Can refer to Images --> Dorsal block splint
8. A man had motor vehicle accident. He was having unstable pelvic ring fracture. What is the
immediate management?
a) Pelvic binder

9.Post MVA. Bilateral conjunctival petechiae. How to confirm diagnosis?

A.Chest CT contrast
B.Urine fat globule
C.Arterial blood gas
D.Chest X-ray

10. A diver complain of left hip pain and limping. No history of trauma or fall. On examination, limited
ROM of left hip? What’s the most likely diagnosis?
Avascular necrosis of left femoral head ( Dysbaric osteonecrosis, also known as Caisson disease & the
bends)
11. A man come in after MVA, complain of shooting pain down the upper limbs. What is your first priority
management?
a. Give supplementary oxygen
b. Hard cervical collar
c. Order urgent lateral X-ray of cervical spine
d. Secondary survey of cervical spine examination